DR.

DANIELE MANFREDINI (Orcid ID : 0000-0002-4352-3085)

Accepted Article
Article type : Review

TEMPOROMANDIBULAR DISORDERS AND DENTAL OCCLUSION. A

SYSTEMATIC REVIEW OF ASSOCIATION STUDIES: END OF AN ERA?

Daniele Manfredini, Luca Lombardo, Giuseppe Siciliani

Post-graduate School in Orthodontics, University of Ferrara, Ferrara, Italy

Running Head

Temporomandibular disorders and dental occlusion

Conflicts of interest

The authors have stated explicitly that there are no conflicts of interest in connection with this
article.

Funding

The authors did not receive any funding to prepare this manuscript

Correspondence

Daniele Manfredini, DDS, PhD

Via Ingolstadt 3

5400 Marina di Carrara (MS)

Italy

daniele.manfredini@tin.it

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/joor.12531
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 ABSTRACT
Aim: To answer a clinical research question: “is there any association between features of
Accepted Article
dental occlusion and temporomandibular disorders (TMD)?”
Methods: A systematic literature review was performed. Inclusion was based on: 1. the type
of study, viz., clinical studies on adults assessing the association between TMD (e.g., signs,
symptoms, specific diagnoses) and features of dental occlusion by means of single or multiple
variable analysis, and 2. their internal validity, viz., use of clinical assessment approaches to TMD
diagnosis.
Results: The search accounted for 25 papers included in the review, 10 of which with
multiple variable analysis. Quality assessment showed some possible shortcomings, mainly related
with the unspecified representativeness of study populations. Seventeen (N=17) articles compared
TMD patients with non-TMD individuals, whilst 8 papers compared the features of dental occlusion
in individuals with TMD signs/symptoms and healthy subjects in non-patient populations. Findings
are quite consistent toward a lack of clinically-relevant association between TMD and dental
occlusion. Only 2 (i.e., centric relation [CR]-maximum intercuspation [MI] slide and mediotrusive
interferences) of the almost forty occlusion features evaluated in the various studies were
associated with TMD in the majority (e.g., at least 50%) of single variable analyses in patient
populations. Only mediotrusive interferences are associated with TMD in the majority of multiple
variable analyses. Such association does not imply a causal relationship and may even have opposite
implications than commonly believed (i.e., interferences being the result, and not the cause, of
TMD).
Conclusions: Findings support the absence of a disease-specific association. Based on that,
there seems to lack ground to further hypothesize a role for dental occlusion in the pathophysiology
of TMD. Clinicians are encouraged to abandon the old gnathological paradigm in TMD practice.

KEYWORDS
Dental occlusion; Temporomandibular disorders; TMD; Association; Systematic review.

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 INTRODUCTION
The relationship between dental occlusion and temporomandibular disorders (TMD) is still a
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controversial topic in dentistry. Indeed, whilst communities of orofacial pain experts seem to have
embraced a biopsychosocial model of TMD,1 within the broader context of orofacial pain
conditions,2 professionals focusing on the study and restoration of dental occlusion (i.e.,
orthodontists, prosthodontists, restorative dentists) are historically less prone to accept concepts
that diminish the importance of occlusal dogmas.3 Thus, the occlusion-TMD field is still often source
of speculations.
TMDs are a heterogeneous group of conditions affecting the temporomandibular joints
(TMJ), the jaw muscles, and /or the related structures.4 Their prevalence is not negligible at the
general population level,5 and patient populations are characterized by relevant psychosocial
impairment, which is often unrelated to the physical diagnosis.6
Dental occlusion is the core of dentistry. Decades of researches have progressively shed light
to many issues concerning the management of occlusion in the clinical practice.7 A purported causal
relationship between “malocclusion” and TMDs has been advocated for years by the precepts of
gnathology,8 but the occlusal paradigm for TMD has never been convincingly validated.9
Observations that conservative management of TMD symptoms is almost always enough to achieve
positive outcomes,10 and that chronic pain subjects are individuals with specific personality, and not
occlusal, profiles,11-13 support the concept of neutrality as far as the effects of occlusal therapies on
TMDs are concerned.14-16
Notwithstanding, this did not reduce the impact of occlusion-related issues in the field of
TMD and orofacial pain, as easily perceivable with a look at popular information channels. Thus, a
gap still exists between the research clinicians and the communities of dental practitioners. A
possible explanation is that the association between dental occlusion and TMDs has never been
reviewed systematically. The available knowledge is mainly based on seminal papers and
comprehensive reviews, which suggest clinicians to focus on other factors than dental occlusion to
manage effectively TMD patients but failed to provide an end-point to the gnathological era.17-19
Indeed, on the other hand, the absence of a systematic approach to literature assessment so far may
justify some controversial claims that the “occlusal question” is still unsolved.20,21
Based on these premises, this manuscript attempts to review the literature to answer a
clinical research question: “Is there any association between features of dental occlusion and
temporomandibular disorders?”

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 MATERIALS AND METHODS
- Search strategy
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th
On January 18 , 2017, a systematic search in the medical literature was performed to identify all
peer-reviewed English language papers that were relevant to the review’s aim. As a first step, a
search query “dental occlusion (MeSH term)” AND “temporomandibular joint disorders (MeSH term)
was performed within the National Library of Medicine’s Medline database to retrieve a list of
potentially relevant papers. Limits were set to English-language studies on humans, with an available
abstract. Based on title and abstract (TiAb) assessment, the studies were selected for full-text
retrieval and potential inclusion independently by two of the authors (D.M, L.L.), who also
performed data extraction by consensus decision. Both authors contributed to the search expansion
by checking for additional papers in the Scopus and Google Scholar databases, in the reference lists
of potentially relevant papers, and in their own personal and institutional libraries.
The criteria for admittance in the systematic review were based on: 1. the type of study, viz.,
clinical studies on human adult populations assessing the association between temporomandibular
disorders (e.g., signs, symptoms, specific diagnoses) and features of dental occlusion by means of
single or multiple variable analysis, and 2. their internal validity, viz., use of validated clinical or
radiological assessment approaches to TMD diagnosis. Investigations with case-control design
(selected populations of TMD patients vs non-TMD individuals) as well as studies assessing the TMD-
dental occlusion association at the general population level (i.e., non-patient populations) were both
included. Studies on self-reported TMD diagnosis and/or unclear protocols to assess occlusal
features were excluded.
- Systematic assessment of papers
The methodological characteristics of the selected papers were assessed based on a format that
enabled a structured summary of the articles in relation to four main issues, viz., ‘P’ -
patients/problem/population, ‘I’ - intervention, ‘C’ - comparison, and ‘O’ - outcome (PICO), for each
of which specific questions were constructed.22
For each article, the study population (‘P’) was described based on the criteria for inclusion
and the demographic features of the non-TMD individuals. The study design was described in the
section reserved to questions on the study intervention (‘I’), and information was gathered on the
type and number of occlusal features under investigation. The comparison criterion (‘C’) was based
on the description of the TMD patients. The study outcome (‘O’) was evaluated in relation to the
measures of association between the assessed occlusal features and TMD, either with single or
multiple variable analyses.

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 - Quality assessment
Critical appraisal of studies included in the review was performed based on the Newcastle-
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Ottawa Scale (NOS) for case-controls studies. NOS assesses the quality of reviewed studies by
evaluating eight items concerning the Selection, Comparability and Exposure categories.
The Selection category consists of four items: case definition, representativeness of cases,
selection of controls and definition of controls. In this review, case definition was considered
adequate when cases (i.e., TMD patients) were identified with clinical and/or imaging assessment for
TMD status; case representativeness was judged positively when they were recruited consecutively;
selection of controls was endorsed for community samples; definition of controls was considered
adequate when they had no history and no current presence of TMD signs and/or symptoms.
The Comparability category is made of a single item evaluating the comparability of cases
and controls based on the design or analysis. The study was endorsed positively if it controls for
dental occlusal variables by adopting a multiple variable design and/or it controls for additional
factors (e.g., bruxism, psychosocial factors).
The exposure category consists of three items, assessing the ascertainment of exposure (i.e.,
dental occlusion features), the use of the same method of ascertainment for cases and controls, and
the non-response rate. Ascertainment was considered adequate if the assessment of dental
occlusion was based on clinical examination and/or evaluation of dental casts, for both cases and
controls. The non-response rate item was endorsed positively when it was clearly specified the
number of non-respondent individuals with respect to the total of invited/recruitable people.
Based on the above, a study can be awarded a maximum of one star for each item within the
Selection and Exposure categories. A maximum of two stars can be given for Comparability. Thus,
the highest quality studies are assigned a score of 9.

RESULTS
- Search results
The search allowed identifying 1670 citations in the Medline database, 848 of which were excluded
when search limits were applied. Thus, 822 citations were screened for eligibility. As shown in Figure
1, after excluding the citations that were clearly not pertinent for the review’s aim based on their
title and abstract, 46 papers were retrieved in full text and were assessed to reach consensus as to
include/exclude the papers for/from systematic assessment. Consensus decision was to exclude 25
of the 46 papers. Reasons for exclusion were described in Table 1. Search expansion strategies
allowed including 4 additional papers, thus accounting for a total of 25 papers included in the
review.48-72

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 - Study findings
Seventeen (N=17) of the included studies had a case-control design, comparing a population of TMD
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patients with non-TMD individuals, whilst 8 papers compared the features of dental occlusion in
individuals with TMD signs/symptoms and healthy subjects in non-patient populations. Structured
reading of the included articles showed a high variability as far as the occlusal features under
evaluation and the TMD diagnosis (i.e., muscle, joint, or combined disorders) are concerned.
Anterior vertical (i.e., overbite) and horizontal overlap (i.e., overjet), and slide from centric relation
(CR) to maximum intercuspation (MI) were the most frequently investigated occlusal features.
Multiple variable analysis was performed only in 10 papers, whilst the other investigations provide
an evaluation of the association between TMD and some selected occlusal features by means of
single variable analysis. Given the heterogeneity of study designs, meta-analysis of data or quality
assessment could not be performed. Methodological features and main findings concerning the
possible association between dental occlusion and temporomandibular disorders in patients and
non-patient populations are summarized in tables 2 and 3.
In summary, the pattern of described association is quite consistent across studies toward a
lack of clinically-relevant association between TMD and dental occlusion. Only two (i.e, CR-MI slide
and mediotrusive interferences) of the almost forty dental occlusion features that have been
evaluated in the different studies are associated with TMD in the majority (i.e., at least 50%) of
single variable analyses in patient populations, and only mediotrusive interferences are associated
with TMD in the majority of multiple variable analyses, with an OR of 2.45 for myofascial pain 57 and
2.14 for disc displacement.64 Other potential clinically-relevant odds ratio (OR) for TMD (i.e., higher
than 2) in multiple variable analysis are reported occasionally. Summary of findings per each of the
most frequently investigated occlusal feature are reported in table 4.
- Quality assessment
Of the 25 papers included in the review, only two received an 8-star score. The majority of
papers felt within the 4-to-6-star range. The most common shortcomings were the unspecified
representativeness of the cases and unclear non-response rate. Thus, when considering the quality
of the selected articles, the assessment showed the moderate level of the reviewed articles as well
as their qualitative homogeneity. However, their methodological heterogeneity prevented a meta-
analysis of data (Table 5).

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 DISCUSSION
For years, the focus of dental professionals approaching patients with temporomandibular disorders
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has been solely based on the assessment and correction of purported abnormalities of dental
occlusion.7 Over the past few decades, emerging evidence has grown in support of a biopsychosocial
model of TMD pain.73 Notwithstanding that, it seems that the new paradigm diminishing the role of
occlusal factors has not been fully accepted by some dental clinicians. There are several possible
explanations for this resistance.
First, the dental profession has historically played a primary role as the caregivers for TMD
patients. In addition, financial disincentives associated with the reduced importance of dental
occlusion as well as patients’ expectations to receive a dentally-oriented treatment contribute to
limit the acceptance of other concepts and practices. Finally, clinical observations of paradox
effectiveness of seemingly occlusally-oriented therapies (e.g., oral appliances) have persuaded many
clinicians to continue using those approaches. Such difficulties can be easily appraised by browsing
the internet and giving a look at the number of congresses, events, and technological devices that
still focus on the search for an ideal occlusion in “dysfunctional” patients. Speculative theories on
the relationship between body posture and occlusal abnormalities, which have been refuted by all
reviews on the topic,18,74 best exemplify the situation. On the other hand, a definitive summary of
the relationship between TMD and dental occlusion has not been provided so far. The heterogeneity
of literature as far as the study designs and research methods are concerned may explain why most
current state-of-the-art reviews are more narrative than systematic.17
A cause-and-effect relationship between two phenomena can be hypothesized with the
accomplishment of a set of criteria for causality (e.g., strong and consistent association; temporality;
theoretical and experimental validity; dose-response relationship; specificity, coherence and analogy
with available knowledge).75 Among those criteria, the presence of an association between the two
conditions (i.e., the purported causal factor [dental “malocclusion”} should be significantly more
frequent in diseased [“TMD”] than healthy subjects, as well as diseased individuals should have a
higher frequency of the purported causal factor than its absence) is the basic pre-requisite to get
deeper into the assessment of causal hypothesis. This manuscript has systematically reviewed the
literature on the topic, by including all papers that may be pertinent for the assessment of the
association between dental occlusion features and TMD, on the premise that such associations are
the first requirement for even considering a causal relationship between them.
Findings of this reviews support the absence of consistent, clinically-relevant associations
between TMD and the various features of dental occlusion. Reported associations were scarce,
weak, and mainly drawn from studies with a single-variable design. Multiple variable analyses

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 described associations that reached strength for possible clinical relevance only in a few papers on
patient 48,57,59,64,66 or non-patient populations.56,60 Each of those papers identified no more than two
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occlusal variables in association with TMD among the full spectrum of features under investigation
(i.e., ranging from six to thirty-three). Conversely, each of those variables was not associated with
TMD in more than a single paper. In short, patterns of association are not consistent across studies,
and may even be due to chance. Thus, the absence of the fundamental pre-requisite of association
between the two phenomena leads to conclude that a causal role for dental occlusion in
temporomandibular disorders should not be hypothesized.
Such findings may offer some interesting arguments for discussion. First, there is a scarce
literature on the topic, and the quality of reviewed articles was, on average, less than optimal. Such
finding contrasts with the number of papers on the different strategies to correct purported
abnormalities of dental occlusion by means of orthodontics or prosthodontic treatments and calls
into question the ethical principles of medicine.76,77 Second, there is a wide methodological
variability between the different investigations as for the assessed TMD signs and symptoms. The
studies adopting multiple variable models, which best depict the biological system, comprehend a
very wide range of morphological and functional occlusal variables. Such a variability of contents
makes meta-analysis of findings not possible and limit the generalization of quality assessment.
Despite that, it should be borne in mind that studies performing a single variable assessment of the
TMD-occlusion assessment as well as those recruiting general population subjects or selected cohort
of non-patients are potentially at high risk of bias. Third, some clinical observations should be made
with respect to the possible interpretation of the described weak associations. Indeed, despite the
fact that dental literature has predominantly been directed toward the view of dental occlusion as
the cause of TMDs, the inverse relationship may even be more plausible and should have been
considered to explain the occasionally-described association between cross-sectionally observed
phenomena. For instance, the association between unilateral cross bite and TMJ disorders, which
was described in three studies, has been recently shown to be independent on the correction of
cross bite.47 This means that in patients with TMJ disorders, the presence of cross bite is not
causative of the joint pathology, but it could be even viewed as the consequence of a certain skeletal
morphology. A similar conclusion can be reached in the case of sagittal skeletal profiles that are
associated with an increased risk for disc displacement.78 Such suggestion is in line with recent
observations that orthodontics is neutral as far as the temporomandibular disorders are
concerned.16 Similar suggestions have been proposed also for the purported relationship between
anterior open bite and TMJ osteoarthrosis, with the former being the consequence, rather than the
cause, of the latter.59 Moreover, the findings of a higher prevalence of CR-MI slide and functional

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 interferences in TMD patients, as reported by a few papers,57,66 can be explained with the pain-
related adaptation of motor functioning, rather than considered the cause of pain.79-81
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In summary, it can be concluded that some significant associations between occlusal
variables and TMD have been occasionally described, but they are not consistent across studies (i.e.,
reported in most researches). Alternative explanations for the presence of such features in TMD
patients with respect to their purported causal role (e.g., consequence of peculiar skeletal anatomy
or TMJ disease) tended to be ignored by the dental communities over the past few decades.3,7 In
addition, epidemiologic studies of dental occlusion have demonstrated that purported malocclusions
and occlusal dysharmonies should be viewed as ancillary findings that are also present with the
same frequency in non-TMD patients.82 Thus, even the pre-requisite to hypothesize a causal role for
dental occlusion in TMD patients, viz., the presence of a strong and consistent association between
the two phenomena (i.e., occlusal feature and TMD), is lacking. On the contrary, the literature is
strong and consistent to support the role of other factors, such as psychosocial and genetic issues as
well as muscle-related overload, in the pathophysiology of temporomandibular disorders.1,2,83
Such observations should ideally lead to an end of the so-called “gnathological era” of
etiological thinking in the TMD field, in which normal variability in the inter-individual features of
dental occlusion has been considered a pathological sign. Based on this suggestion, future teaching
about these topics for the dental specialties working on the correction of dental occlusion should be
introduced in their academic training as well as in their clinical practices.

CONCLUSIONS
This manuscript reviewed the literature on the association between features of dental occlusion and
temporomandibular disorders. Based on findings, which support the absence of a disease-specific
association, there is no ground to hypothesize a major role for dental occlusion in the
pathophysiology of TMDs. Dental clinicians are thus encouraged to move forward and abandon the
old-fashioned gnathological paradigm.

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49. Hiltunen K, Vehkalahti M, Ainamo A. Occlusal imbalance and temporomandibular disorders
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variables and intraarticular temporomandibular disorders: molar relationship, lateral guidance, and
nonworking side contacts. J Prosthet Dent 1999; 82: 410-5.
52. Macfarlane TV, Gray RJM, Kincey J, Worthington HV. Factors associated with the
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 53. Celic R, Jerolimov V, Panduric J. A study of influence of occlusal factors and parafunctional
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63. Takayama Y, Miura E, Yuasa M, Kobayashi K, Hosoi T. Comparison of occlusal condition and
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 65. He SS, Deng X, Wamalwa P, Chen S. Correlation between centric relation; maximum
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 79. Lund JP, Donga R, Widmer CG, Stohler CS. The pain-adaptation model: a discussion of the
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2013;14(12 Suppl):T33-50.

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 TABLES
Accepted Article Table 1. Excluded papers after full-text reading.
Main finding(s) –
Study author, year Reason for exclusion
TMD/occlusion
23 Longitudinal study on adolescents, unclear Unilateral contact in ICP at 20 years
Egermark, 1987
data on adulthood associated with TMJ sounds
Dental occlusion features do not
Runge, 198924 No statistical analysis
seem related with TMJ click
25 No validated TMD criteria, unclear statistical Single variable: association between
Al-Hadi, 1993
analysis Class II-1 and TMD
Similar prevalence of mediotrusive
Unclear “TMD” criteria (click sound?), no
Christensen, 199626 tooth guidance in subjects with and
statistical analysis
without joint sounds
Similar prevalence of canine
27 Unclear “TMD” criteria (click sound?), no
Donegan, 1996 guidance in subjects with and
statistical analysis
without joint sounds
Sample containing children and adolescents, No association between
Liu, 199728
unclear data on adulthood morphologic occlusion and TMD
29
Minagi, 1997 Study on TMJ dynamics Not pertinent
Multiple variable: stiffness of the
Study on occlusal support, no validated TMD
Ciancaglini, 199930 jaw associated with loss of occlusal
criteria
support
Significant relative risk for disease
(odds ratio > 2:1) was mainly
31 Combined sample of included 1993 and 2006
Pullinger, 2000 associated with infrequent, more
studies
extreme ranges of occlusion
measurements.
No association with overbite and
John, 200232 Self-report TMD assessment
overjet
33 Interferences more frequent in the
Fuji, 2003 No measure of association
side of pain and clickling
Study on chewing ability and shortened dental
Sarita, 200334 Not pertinent
arch
35 Study on adolescents, unclear data on
Pahkala, 2004 Not pertinent
adulthood
36
Mundt, 2005 Subsample of Gesch et al., 2004 See main paper
37 No relationship between TMD and
Sipila, 2006 Patients with unspecified facial pain
occlusal variables
Sample of patients with tightly locked Single variable: association with
Wang, 200738
occlusion, diagnosed with unspecific criteria unspecified TMD
Single variable: association of TMD
Unmatched age of disc displacement (35.3 yrs)
with reduced OVD and uneven
39 and control (23.4 yrs) groups, unclear criteria
Badel, 2008 dental contacts, no association with
for measuring occlusal vertical dimension
overjet, overbite, non-centered
(OVD)
incisor midline
Sample of patients with missing posterior teeth Multiple variable: number of
Wang, 200940 (no controls without missing posterior teeth), quadrants with missing posterior
generic TMD diagnosis teeth associated with TMD
41 Longitudinal study on students (non-patients),
Marklund, 2010 Not pertinent
unspecific TMD/occlusion relationship
No association with Angle class,
Lauriti, 201342 Study on adolescents
open bite, cross bite
43
Manfredini, 2014 Study on bruxers Multiple variable: only 1 significant

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 (molar asymmetry) out of 11
occlusal features
Accepted Article Manfredini, 201444
Study on the role of extreme occlusal features
Not pertinent
in bruxers
45 No association between TMJ click
Manfredini, 2014 Study on TMD patients, no control group
and 7 occlusal variables
Clinically unrelevant differences
Baldini, 201546 Study on occlusion time
between TMD and TMD-free
Single variable: association between
47
Michelotti, 2016 Longitudinal study, no standardized evaluation click and cross bite independent on
cross bite correction

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ccepted Article
Table 2. Summary of findings of studies comparing the prevalence of dental features in TMD patients vs non-TMD individuals (case-control
design).
Study first
Population (P) Intervention (I) Comparison (C) Outcomes (O)
author, year
Significant associations (per disease) (p<0.05)
Disc Displacement with Reduction: Unilateral lingual crossbite;
Overbite; Dental midline discrepancy; Missing posterior teeth;
RCP-ICP slide length
Disc Displacement without Reduction: Unilateral lingual crossbite;
11 occlusal features First molar relationship
Osteoarthrosis with Disc Displacement History: Anterior open bite;
Anterior open bite; unilateral Unilateral lingual crossbite; Overjet; Missing posterior teeth
maxillary lingual crossbite; RCP-ICP slide length; Disc Displacement with Reduction
Primary Osteoarthrosis: Anterior open bite; Overjet; Missing
RCP-ICP slide; unilateral RCP contact; overbite; (n= 81), Disc Displacement without
Pullinger, posterior teeth; RCP-ICP slide length
N=147 asymptomatics overjet; dental midline Reduction (n = 48), Osteoarthrosis
199348 Myalgia Only: Anterior open bite; Unilateral lingual crossbite;
discrepancy; number of missing teeth; the greater with Disc Displacement History (n =
Overjet; RCP-ICP slide length
of the mesio-distal intermaxillary relationship 75), Primary Osteoarthrosis (n =
discrepancies at the first molar location; first molar 85), and Myalgia Only (n =124).
Clinically relevant associations (per occlusal factor) (OR>2)
intermaxillary relationship (right vs. left Anterior open bite:
asymmetry) Osteoarthrosis with disc displacement history OR=7.39
Primary osteoarthrosis OR=7.27
Myalgia only OR=7.55
Unilateral lingual crossbite:
Disc displacement with reduction OR=3.33
Disc displacement without reduction OR=2.64
N=82 asymptomatics
2 occlusal features N=263 symptomatics (i.e., TMJ
Kahn, (55 with normal TMJ
pain) - 221 with DD, 42 with normal Single variable (p<0.05): Overjet >4mm
199850 disc position, 27 with Overbite; overjet TMJ disc position
DD)
N=82 asymptomatics 3 occlusal features N=263 symptomatics (i.e., TMJ Single variable (p<0.05): Canine guidance (Symptomatic DD);
Kahn, (55 with normal TMJ
Molar relationship; occlusal guidance; Non- pain) - 221 with DD, 42 with normal Absence of one or more non-working contacts (Symptomatic
199951 disc position, 27 with
TMJ disc position normal; symptomatic DD)
DD) working side contacts

N=196 healthy 1 occlusal feature

McFarlane, N=131 subjects with “Pain
subjects aged 18-65 Multiple variable: no association
200152 years Missing posterior teeth dysfunction syndrome”

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ccepted Article N=82 asymptomatics
N=263 symptomatics (i.e., TMJ
Tallents, (55 with normal TMJ 1 occlusal feature Single variable (p<0.05): missing posterior teeth (Symptomatic
pain) - 221 with DD, 42 with normal
200254 disc position, 27 with Missing posterior teeth TMJ disc position
DD)
DD)
8 occlusal features
Single variable (p<0.05): RCP-MI >2mm; mediotrusive
N=49 healthy females RCP-MI slide length, vertical overlap, horizontal interferences; laterotrusive interferences
Landi, N=81 females with myofascial pain
(m.a. 34.8, range 20- overlap, unilateral posterior reverse articulation,
200457 61 years) anterior open occlusal relationship, incisor dental
(m.a. 37.2, range 20-71 years) Multiple variable (p<0.05 and OR): RCP-MI (OR=2.57);
midline discrepancy, mediotrusive interferences, mediotrusive interferences (OR=2.45)
laterotrusive interferences,
N=573 adults (age 35-
Hirsch, 2 occlusal features N=82 adults (age 35-44) and 112 Single variable: no association
44) and 1225 seniors
200558 seniors (age 65-74) with joint noise
(age 65-74) without Overbite, overjet Multiple variable: no association
(click or crepitus)
TMD
9 occlusal features
RCP-ICP slide length; overbite; overjet; unilateral Single variable (p<0.05): RCP-MI slide length; unilateral posterior
N=47 asymptomatic N=124 female patients with
Seligman, posterior crossbite; anterior open bite; incisor crossbite
females (m.a. 41.2 ± intracapsular TMD - 51 DD, 73 OA
200659 15.48, range 21-74 dental midline discrepancy; number of unreplaced (m.a. 35.4 ± 11.89, range 13-72 Multiple variable (p<0.05 and OR): RCP-MI (OR=1.33); unilateral
years) missing posterior teeth; first molar mesiodistal years) posterior crossbite (OR=11.67)
relationship; right and left first molar position
asymmetry
8 occlusal features
Selaimen, N=30 pain-free Overbite, overjet, number of anterior teeth, N=72 myofascial pain females (15- Single variable (p<0.05): Absence of canine guidance; Angle class
200761 females (15-60 years) number of posterior teeth, Angle class, bilateral 60 years) II
canine guidance on lateral excursion, bilateral
canine guidance of protrusion, anterior CR-CO slide
Takayama, N=970 dental patients 1 occlusal feature Single variable (p<0.05): More occlusal support in TMD than
N=504 TMD patients aged>25 years
200863 aged >25 years Occlusal support (Eichner index) dental patients

12 occlusal features
Single variable (p<0.05): slide RCP-ICP, mediotrusive
N=145 healthy Cross bite, open bite, overbite, scissor bite, N=165 subjects with disc interferences, absence of bilateral canine guidance
Chiappe, overjet, incisor midline, canine Angle class, molar
subjects (65 males; displacement alone (65 males; m.a. Multiple variable (p<0.05 and OR): absence of bilateral canine
200964 m.a. 31.0 yrs) Angle class, slide RCP-ICP, occlusal guidance, 32.5 yrs) guidance (OR=2.84); mediotrusive interferences (OR=2.14); slide
mediotrusive interferences, laterotrusive
RCP-ICP (OR=1.75)
interferences

He, 201065 N=70 students (20-30 1 occlusal feature N=107 pre-treated orthodontic Single variable (p<0.05): CR-MI slide

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ccepted Article years) CR-MI slide TMD patients (18-32 years)
8 occlusal features
Single variable (p<0.05): Overjet >4mm
Manfredini, N=166 pain-free RCP-MI slide length; vertical overlap; horizontal
N=110 TMJ pain subjects Multiple variable (p<0.05 and OR): Overjet >4mm (OR=2.83);
201066 subjects overlap; posterior reverse articulation; anterior
open bite; mediotrusive and laterotrusive laterotrusive interferences (OR=2.67)
interferences
N=31 TMD-free 1 occlusal feature
Wang, N=31 TMD subjects (19-31 years)
subjects (19-31 years) Single variable (p<0.05): Premature contact in ICP
201267 with normal occlusion Premature contact in ICP with normal occlusion

6 occlusal features
Halalur, N=50 healthy subjects N=50 subjects (18-35 years) with at Single variable (p<0.05): group function; CR-CO slide; balancing
Type of occlusion; CR-CO Slide; Balancing
201368 (18-35 years)
Interferences; Working interferences; Protrusive
least one TMD signs or symptoms interferences
Interferences; Loss of Vertical height
5 occlusal features
N=58 TMD-free Single variable: no association
De Sousa,
subjects aged>15 Anterior open bite; Posterior crossbite; Overbite N=42 TMD subjects aged>15
201570 years ≥4mm; Overjet≥5 mm; more than 5 posterior teeth Multiple variable: no association
lost
N=58 TMD-free
3 occlusal features N=96 TMD patients (aged 20-40
Manfredini, subjects (aged 20-40
years) without history of Single variable: no association
201772 years) without history Canine class; molar class; asymmetry orthodontics
of orthodontics

Footnotes: RCP-ICP, Retruded Contact Position-Intercuspal Position (Note for the readers: This was the past acronym for CR-MI [Centric Relation-Maximum
Intercuspation] slide); OR, Odds Ratio; TMJ, Temporomandibular Joint; DD, Disc Displacement; OA, Osteoarthrosis; CR-CO, Centric Relation-Centric
Occlusion.

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ccepted Article
Table 3. Summary of findings of studies comparing the prevalence of dental features in subjects with and without TMD signs/symptoms in
selected cohorts of non-patients.
Study first
Population (P) Intervention (I) Comparison (C) Outcomes (O)
author, year
N=301 subjects with
normal or mild 1 occlusal feature N=63 subjects with moderate or
Hiltunen,
Helkimo dysfunction Occlusal support with and without dentures severe Helkimo dysfunction index Single variable: no association
199749 index (age 76-86 (age 76-86 years)
(Eichner index)
years)*
N=151 non-patients 2 occlusal features Muscle pain non-patients (N=13),
Celic, Single variable (p<0.05): Overjet>4mm (muscle pain; muscle pain +
without TMD (19-28 DDR non-patients (n=21), muscle
200253 years)* Overbite; overjet pain + DDR non-patients (n=45)
DDR); Overbite >4mm (DDR; muscle pain + DDR)

N=15 subjects 1 occlusal feature

Ciancaglini, N=15 Subjects with at least 2 TMD
without TMD (19-26 Single variable: No association
200355 years) Number of occlusal contacts signs or symptoms

27 occlusal features
Upper incisors crowding; lower incisors crowding;
labial/lingual position of one or more canines;
posterior teeth crowding; spacing; Overjet;
Retroclined maxillary incisors; Edge-to-edge bite; Single variable (p<0.05): Posterior crowding; Edge-to-edge bite;
Crossbite anterior; Negative overjet; Distoclusion; negative overjet; distocclusion (1premolar width); bilateral open
Mesioclusion; Mixed occlusion (no specific type); bite up to 3 mm; Unilateral posterior crossbite
N=2997 general Open bite anterior; Open bite posterior; Deep bite; N=1292 general population with
Gesch,
population (20-79 Buccolingually cusp-to-cusp relation (unilateral or two or more TMD signs (20-79 Multiple variable (p<0.05 and OR): edge-to-edge bite (OR=1.5);
200456 years) bilateral); Crossbite posterior (unilateral or years) negative overjet (OR=2.4); bilateral posterior open bite up to
bilateral); Scissors-bite (unilateral or bilateral); 3mm (OR=4.0); unilateral posterior crossbite (OR=1.2)
Normal occlusion; Attrition; Non-working side
interferences (unilateral or bilateral); Protrusion
interferences (unilateral or bilateral); Non-working
side contacts (unilateral or bilateral); Protrusion
contacts (unilateral or bilateral); Non-working side
contacts + wear; lateral contacts on protrusion +
wear
Schmitter, N=136 asymptomatic 6 occlusal features N=15 age- and sex-matched Multiple variable (p<0.05 and OR): Non-occlusion, at least one
200760 females (m.a. 31.05, Overjet, open bite, overbite, missing posterior
females with myofascial pain side (OR=4.2); open bite (OR=3.6)

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ccepted Article range 18-65 yrs) teeth, dental attrition, RCP-ICP slide
N=83 general
population subjects 1 occlusal feature
Witter, Subjects with TMD signs symptoms
followed up for 9 No differences (short vs complete dental arch)
200762 years (m.a. 40 years Short dental arch within the study cohort
at baseline)
8 occlusal features
N=164 undergraduate Slide CR-MI; Mediotrusive interferences;
Ferreira, N=37 undergraduate students with
students without Laterotrusive interferences; Posterior Single variable: no association
201469 TMD (age 20.4 yrs)
Muscle or Joint TMD
interferences; Overjet; Overbite; Cross bite; Open
bite
N=9 non-patients 1 occlusal feature
Tinastepe, N=51 subjects (aged 20-45 years)
with TMD (aged 20-45 Single variable: no association
201571 years)* Deep-bite without TMD

*(Data extracted by this review’s authors)

Footnotes: DDR, Disc Displacement with Reduction; RCP-ICP, Retruded Contact Position-Intercuspal Position (Note for the readers: This was the past
acronym for CR-MI [Centric Relation-Maximum Intercuspation] slide); OR, Odds Ratio.

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 Table 4. Summary of findings of studies adopting multiple variable analysis: number of
Accepted Article
papers reporting the presence and absence of an association with TMD per each of the most
frequently investigated occlusal feature. For positive associations, reported OR and the TMD
category are put in parentheses.

Occlusal features Non-patient studies Patient studies

Association: N=0 Association N=1 (OR 2.83 for TMJ pain)
Overjet
No association: N=2 No association N=8
Association: N=0 Association: N=0
Overbite
No association: N=2 No association: N=10
Association: N=2 (anterior open bite OR 3.6
for myofascial pain; posterior open bite OR Association: N=1 (OR 7.27 for osteoarthrosis)
Open Bite 4.0 for TMD) No association: N=8
No association: N=1
Association: N=3 (OR 3.33 for DDR, OR 2.64 for
Unilateral Cross Association: N=0
DDNR, OR 11.67 for intracapsular TMD)
Bite No association: N=1
No association: N=6
Association: N=0 Association: N=1 (OR 2.57 for myofascial pain)
CR-MI Slide
No association: N=1 No association: N=8
Midline Association: N=0 Association: N=0
Discrepancy No association: N=4 No association: N=8
Posterior Missing Association: N=1 (OR 4.2 for myofascial pain) Association: N=0
Teeth No association: N=1 No association: N=8
Association: N=0 Association: N=0
Molar Class
No association: N=1 No association: N=5
Association: N=0
Molar Asymmetry -
No association: N=5
Association: N=2 (OR 2.45 for myofascial pain;
Mediotrusive Association: N=0
OR 2.14 for disc displacement)
Interferences No association: N=1
No association: N=1
Laterotrusive Association: N=0 Association: N=1 (OR 2.67 for TMJ pain)
Interferences No association: N=1 No association: N=2
Footnotes: OR, Odds Ratio; TMJ, Temporomandibular Joint; DDR, Disc Displacement with Reduction;
DDNR, Disc Displacement without Reduction.

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 Table 5. Quality assessment of reviewed articles based on the Newcastle-Ottawa Scale.
Accepted Article SELECTION
COMPARA EXPOSURE (DENTAL
BILITY OCCLUSION)
Comparabi Same
Study Is the lity of method
first Selec Defini
case cases and of Non-
Representati tion tion Ascertain
author, definiti
veness of of of
controls on
ment of
ascertain respo
year on the basis ment for nse
the cases contr contr exposure
adequ of the cases rate
ols ols
ate? design or and
analysis controls
Pulling
er,
199348
Hiltune
n,
199749
Kahn,
199850
Kahn,
199951
McFarl
ane,
200152
Celic,
200253
Tallent
s,
200254
Ciancag
lini,
200355
Gesch,
200456
Landi,
200457
Hirsch,
200558
Seligm
an,
200659
Schmitt
er,
200760
Selaim
en,
200761
Witter,
200762
Takaya
ma,

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 200863
Chiapp
Accepted Article e,
200964
He,
201065
Manfre
dini,
201066
Wang,
201267
Halalur
, 201368
Ferreir
a,
201469
De
Sousa,
201570
Tinaste
pe,
201571
Manfre
dini,
201772

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Accepted Article

This article is protected by copyright. All rights reserved.